2013 home health workshop series handout - appendixfi… · xxxxx 6. patient’s name and ......
TRANSCRIPT
Appendix
Home Health Certification and Plan of Care Sample Face-to-Face Encounter 1 Sample Face-to-Face Encounter 2 12 Basic Rules of Documentation Documenting Pain Pain Drawing Pain Measurement Tools Pain Ladder Memorial Pain Assessment Card Wong-Baker FACES Scale Pain Affect Faces Scale “Ouchier” Pain Measurement Tool Workshop Question Form
1. Patients HI Claim No. xxx-xx-xxxx 2. Start of Care Date
03/17/12 3. Certification Period From: 03/17/12 To: 05/15/2012
4. Medical Record # Xxxxxxxx 5. Provider #
xxxxx 6. Patient’s Name and Address Perry Cardium 1313 Mockingbird Lane Mockingbird Heights, California
7. Provider’s Name, Address and Telephone Number Bedrock Home health Agency 1313 Cobblestone Way Bedrock, California
8. Date of Birth: 01/17/1945 9. M x F �
11. ICD-9-CM 438.21 Principal Diagnosis
Late effect hemiplegia dom side Date 3/17/12
10. Medications: Dose, frequency/Route (N)ew (C)hanged Hydrazaline daily previous Aspirin daily previous Plavix daily previous
12. ICD-9-CM Surgical Procedures Date 13. ICD-9-CM 402.90 530.81
Other Pertinent Diagnoses Unspecified hypertensive heart disease without heart failure Esophageal reflux
Date 3/17/12 3/17/12
14. DME and Supplies Lift, walker, wheelchair, hospital bed 15. Safety Measures: Side rails, up, items within reach, anticoagulant precautions, safe transfers, fall precautions, medication safety
16. Nutritional Req. 2 gram sodium 17. Allergies: nkda 18.A Functional Limitations 1. � Amputation 5.� Paralysis 9. � Legally Blind 2. x B/B Incont. 6. x Endurance A � Dyspnea w/ min. Ex. 3. � Contracture 7. x Ambulation B � Other(specify) 4. x Hearing 8. � Speech
18.B Activities Permitted 1. � Complete Bedrest 6. � Partial Weight Bearing A � Wheelchair 2. � Bedrest BRP 7. � Independent at home B � Walker 3. � Up as Tolerated 8. � Crutches C � No Restriction 4. x Transfer bed/chair 9. � Cane D � Other 5. � Exercises Prescribed
19. Mental Status: 1.� Oriented 3. � Forgetful 5.� Disoriented 7.� Agitated 2.� Comatose 4 .x Depressed 6.� Lethargic 8.� Other
20. Prognosis: 1.x Poor 2.� Guarded 3.� Fair 4.� Good 5.� Excellent 21. Orders for Discipline and Treatments (SpecifyAmount/Frequency/Duration) Skilled nurse to:
- report vital signs exceeding the following ranges: BP 90/50-170/100, p-60-100, R 14/28, temp 96.0-99.0 - Assess caregiver knowledge deficits and teach accordingly - Assess skin status, instruct on measure to reduce risk of ulcer development
22. Goals/Rehabilitation Potential/Discharge Plans Patient will feel better Patient will not get any worse 23. Nurse’s Signature and Date Betty Jean Rubble RN 3/20/12 25. Date HHA Received Signed POT
04/10/12 24. Physician’s Name and Address Joe Rockhead 1212 Boulder Lane Bedrock, California
26. I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and or speech therapy or continues to need occupational therapy. The patient is under my care and I have authorized the services on this plan of care and will periodically review the plan
27. Attending Physician’s Signature and Date Signed Joe Rockhead 4/4/12
28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 1
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 2
Doctor’s Mart 565 North Clinton Drive Milwaukee Wisconsin Patient name: Casper D Ghost Date of Birth: 05/09/1932 Date of Service: 11/26/2012 Provider: Victor Frankenstein Agency: Can’t Wait to Get Home Health Agency Agency phone number: 555 555-5554 Face to Face Encounter I certify that this patient is under my care and that I had a face to face encounter that
meets the Medicare provider face to face encounter requirements with this patient on: 11/26/2012 The Encounter with the patient was in whole, or in part, for the following medical
condition, which is the primary reason for home health care: Diabetes Type 2 250.00 I certify that based on my findings, the following services are medically necessary home
health services: Skilled Nursing The clinical findings that support the need for the above services because: Monitor blood sugars Teach s/s of hyper/hypoglycemia Further, I certify that my clinical findings support that this patient is homebound (i.e.
absences from the home require considerable effort and are for medical reasons, religious
services or infrequently or of short duration because: Leaving home is a considerable taxing effort Provider: Victor Frankenstein 11/26/2012
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 3
Sample Face-to-Face Encounter 1
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 4
Doctor’s r’ Us Physician services 328 Chauncey Street, Brooklyn, NY 11201
Patient name: Oliver Hardy Date of Birth: 02/09/1918 Date of Serivce: 10/27/2011 Provider: Victor Von Doom Agency: Can’t Wait to Get Home Health Agency Agency phone number: 555 555-5554 Start of Care/Face to Face Encounter I certify that this patient is under my care and that I had a face to face encounter that meets the Medicare provider face to face encounter requirements with this patient on: 10/27/2011 at 2:45 The Encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care: 401.9 Hypertension I certify that based on my findings, the following services are medically necessary home health services: Skilled Nursing The clinical findings that support the need for the above services because: Monitor BP Teach fall precautions Ensure medication compliance Do labs as ordered Further, I certify that my clinical findings support that this patient is homebound (i.e. absences from the home require considerable effort and are for medical reasons, religious services or infrequently or of short duration because: Due to osteoarthritis Provider: Victor Von Doom 10/27/2011
Sample Face-to-Face Encounter 2
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 5
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 6
McCaffery and Beebe (1989). Pain: Clinical manual for nursing practice. St. Louis: CV Mosby Co. .
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 7
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 8
Huskisson S. Measurement of pain. J Rheumatol 1982; 9: 768
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 9
Pain Ladder
Jeans & Johnston, 1985] Jeans, M.E.; Johnston, C.C. Pain in children: assessment and management In Lipton, Miles "Persistent Pain: Modern Methods of Treatment", vol. 5,
pp. 111-127. Grune & Stratton, London.
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 10
Memorial Pain Assessment Card
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 11
Wong-Baker FACES Scale
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 12
Pain Affect Faces Scale
Patt RB. Cancer pain. Philadelphia: JB Lippincott Co.; 1993
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 13
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 14
1. Patients HI Claim No. xxx-xx-xxxxA 2. Start of Care Date
11/01/2012 3. Certification Period From: To: 11/01/2012 12/30/2012
4. Medical Record # Xxx
5. Provider # xxxxxx
6. Patient’s Name and Address Cora Narrie 7. Provider’s Name, Address and Telephone Number
8. Date of Birth: 07/09/1925 9. M � F x
11. ICD-9-CM 428.0 Principal Diagnosis
CHF (E)
Date 10/15/2012 10. Medications: Dose, frequency/Route (N)ew (C)hanged
Coumadin 2 mg p.o. at bedtime (C) Prinivil 20 mg p.o. daily (N) Lanoxin 0.125 mg p.o. daily (N) Levaquin 250 mg p.o. daily x 5 days (N) Colace 100 mg p.o. twice daily (N) Protonix 40 mg p.o. daily (N) Mucinex DM ½ tablet p.o. twice daily (N) Paxil 40 mg p.o. daily (N) Restoril 7.5 mg p.o. at bedtime as needed for sleep (N) Levoxyl 112 mg p.o. daily (N) Ativan 0.5 mg tablet p.o. every 6 hours as needed for agitation/anxiety (N) Lasix 20 mg p.o. every other day (N) Phenergan 12.5 mg p.o. every 4 hours as needed for nausea (N) Toprol XL 100 mg p.o. twice daily (N) KCL 10 meq p.o. every other day only with lasix (N)
12. ICD-9-CM Surgical Procedures n\a Date
13. ICD-9-CM 290.4 401.9 427.31
Other Pertinent Diagnoses Vascular dementia (N) Hypertension (E) Atrial fib (E)
Date 10/26/2012 10/26/2012 10/26/12
14. DME and Supplies N/A 15. Safety Measures: Walker 16. Nutritional Req. 2G Na 17. Allergies: NKDA 18.A Functional Limitations 1. � Amputation 5.� Paralysis 9. � Legally Blind 2. � B/B Incont. 6. x Endurance A xDyspnea w/ min. Ex. 3. � Contracture 7. x Ambulation B � Other(specify) 4. x Hearing 8. � Speech
18.B Activities Permitted 1. � Complete Bedrest 6. � Partial Weight Bearing A x Wheelchair 2. � Bedrest BRP 7. � Independent at home B x Walker 3. x Up as Tolerated 8. � Crutches C � No Restriction 4. � Transfer bed/chair 9. � Cane D � Other 5. � Exercises Prescribed
19. Mental Status: 1.x Oriented 3. xForgetful 5.� Disoriented 7.� Agitated 2.� Comatose 4 .� Depressed 6.� Lethargic 8.� Other
20. Prognosis: 1.� Poor 2.� Guarded 3.x Fair 4.� Good 5.� Excellent 21. Orders for Discipline and Treatments (SpecifyAmount/Frequency/Duration) 22. Goals/Rehabilitation Potential/Discharge Plans 23. Nurse’s Signature and Date 25. Date HHA Received Signed POT 24. Physician’s Name and Address 26. I certify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical
therapy and or speech therapy or continues to need occupational therapy. The patient is under my care and I have authorized the services on this plan of care and will periodically review the plan
27. Attending Physician’s Signature and Date Signed 28. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 15
Question Contact Form
Workshop Location and Date:_____________________________________________
Name: _______________________________________________________________
Position or Title: _______________________________________________________
Agency Name: _________________________________________________________
Provider #: ____________________________________________________________
Phone #: _____________________________________________________________
Fax #: _______________________________________________________________
Email: _______________________________________________________________
Question(s):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Disclaimer: This form is for use in conveying general questions only and may not contain information that is privileged and confidential, specifically Protected Health Information (PHI). If you have a question about a specific claim, please request a call for follow up. Thank you. Revision #1 Revision date 08-02-2006 MR-QSF-7.5.1 LPET – Question Contact Form
2013 Home Health Workshop Series - Appendix
June 2013 Palmetto GBA - J11 Medicare Administrative Contractor (MAC) 16